Should anti-vitamin K be started on the first day in non-high risk pulmonary embolism?

Goran Pante Koraćević; Dragana Ilić

doi:10.2298/VSP170121001K

Goran Pante Koraćević Department for Cardiovascular Diseases, Clinical Center Nis, and Medical Faculty, University of Nis
Dragana Ilić Clinical Center Nis Department of Radiology University of Nis, Nis, Serbia

DOI: https://doi.org/10.2298/VSP170121001K

Keywords: pulmonary embolism;, anticoagulants;, computed tomography angiography;, lung;, fibrin fragment d;, treatment outcome

Abstract

Introduction. Protocols and guidelines have been improving results of our clinical practice. Sometimes there have been differences between guidelines on the same topic, but they have not been so important usually. As far as the start of vitamin K antagonists (VKA) in a non-high risk pulmonary thromboembolism (PTE) patients is concerned, there is global consensus (reflected in all comprehensive guidelines) that it should be on the admission day or a day later. However, there are situations in which this VKA administering from the first (or second) day of hospitalization may actually complicate the treatment. Case report. As an illustration, our female, 71 years old patient with second unprovoked, intermediate-high risk PTE was given low-molecular-weight heparin (LMWH) + VKA from the second day. Due to lack of improvement in symptoms, oxygen saturation and D dimer after 9 days, computed tomography pulmonary angiography (CTPA) was repeated and it confirmed minimal advancement. The patient already had achieved target international normalized ratio (INR) and it complicated proceeding to fibrinolytic therapy. Conclusion. Correction of the therapeutic approach in the PTE treatment may be needed even if the treatment is completely conducted according to the latest guidelines. We recommend postponing VKA from the first (or second) day of hospitalization (as suggested in all available guidelines for non-high risk PTE patients) until satisfying clinical improvement is reached.

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